Treatment of rectosigmoid endometriosis by laparoscopic reverse submucosal dissection (LRSD): The Sydney partial thickness discoid excision technique.

BACKGROUND: Laparoscopic reverse submucosal dissection (LRSD) is a standardised surgical technique for removal of rectosigmoid endometriosis which optimises the anatomical dissection plane for excision of endometriotic nodules. AIM: This cohort study assesses the outcomes of the first cohort of women treated by LRSD, for deeply infiltrating rectosigmoid endometriosis. MATERIALS AND METHODS: Primary outcomes assessed were complication rate as defined by the Clavien-Dindo system, and completion of the planned LRSD. Secondary outcomes include mucosal breach, specimen margin involvement, length of hospital admission, and a comparison of pre-operative and post-operative pain, bowel function and quality of life surveys. These included the Endometriosis Health Profile Questionnaire (EHP-30), the Knowles-Eccersley-Scott Symptom Questionnaire (KESS) and the Wexner scale. RESULTS: Of 19 patients treated, one required a segmental resection. The median length of hospital admission was two days (range 1-5) and no post-operative complications occurred. Median pain visual analogue scales (scale 0-10) were higher prior to surgery (dysmenorrhoea 9.0, dyspareunia 7.5, dyschezia 9.0, pelvic pain 6.0) compared to post-surgical median scores (dysmenorrhoea 5.0, dyspareunia 4.0, dyschezia 2.0, pelvic pain 4.0) at a median of six months (range 4-32). Quality of life studies suggested improvement following surgery with pre-operative median EHP-30 and KESS scores (EHP-30: 85 (5-106), KESS score 9 (0-20)) higher than post-operative scores (EHP-30: 48.5 (0-80), KESS score: 3 (0-19)). CONCLUSION: This series highlights the feasibility of LRSD with low associated morbidity as a progression of partial thickness discoid excision (rectal shaving) for the treatment of rectosigmoid deep infiltrating endometriosis.

Superior Hypogastric Plexus Nerve Block in Minimally Invasive Gynecology: A Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the efficacy of a superior hypogastric plexus nerve block in reducing opioid requirements in the first 24 hours after minimally invasive gynecologic surgery. DESIGN: Patient-blinded randomized controlled trial. SETTING: Single-center academic institution (Sydney Women's Endosurgery Centre). Two surgeons administering the blocks in their own surgeries. PATIENTS: Patients undergoing either laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy for benign indications. INTERVENTIONS: Ropivacaine 10 mL (0.75%) infiltrated into the retroperitoneal space overlying the superior hypogastric plexus vs control of no block given at the completion of surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the total opioid use in the first 24 hours after surgery, measured in morphine milligram equivalents (MME). Standardized fentanyl patient-controlled analgesia was given to all patients in the trial. The secondary outcome was pain measured on a visual analog scale (1 to 10) at 1, 2, 6, 12, and 24 hours after surgery. Fifty patients out of 56 approached for the study participated in, and completed, the study (89.2%). The patients were randomized over a 5-month period, March 2020 to July 2020. A total of 27 patients were randomized to receive a nerve block, and 23 were randomized to the control. There was a difference of -21.8 MME in the block group compared with the no-block group (95% confidence interval [CI], -38.2 to -5.5; p = .008). This correlated to a 38% reduction in opioid use in the block group. The mean opioid use in the patients in the block group was 33.1 MME (95% CI, 24.2-41.9) and in those in the no-block group 54.9 MME (95% CI, 40.7-69.1). For the block group, opioid use ranged from 1.0 to 76.5 MME, with an interquartile range of 37 (14-51). For the control group, the range was 7.5 to 113.5 MME, with a higher interquartile range of 60 (28-88). Pairwise comparisons of the mean pain scores over the 24 hours showed a lower pain score with a nerve block of 1.8 (95% CI, 1.5-2.1) compared with a no-block score of 2.6 (95% CI, 2.3-2.9) No adverse effects of local anesthetic toxicity, nerve injury, or bowel/vascular injury were noted in any patient. CONCLUSION: A superior hypogastric plexus nerve block is a simple technique for reducing postoperative opioid requirements and pain in the first 24 hours after minimally invasive gynecologic surgery.

Removing the large uterus without morcellation - The Colpo-V incision for specimen extraction at hysterectomy.

BACKGROUND: Hysterectomy is the most commonly performed benign gynaecological surgery. Recently, the rates of minimally invasive hysterectomy have fallen due to the banning of mechanical morcellation techniques that rendered minimal invasive gynaecology surgeons unable to extract large uteri from the relatively small colpotomy incisions. AIMS: This study aims to share our experience in utilising Colpo-V incision to remove large uterine specimens transvaginally and report its success and complication rates to promote a minimal invasive approach in patients with large uteri without the need to perform large abdominal incisions or transabdominal morcellation. METHODS: This is a prospective case series study in which women with large uteri and|or narrow vaginal canal underwent total laparoscopic hysterectomy and a subsequent posterior vaginal wall incision (Colpo-V) to facilitate the intact extraction of the uterus through the vagina. Patients were seen in the clinic six weeks after the surgery for post-operative assessment and documentation of late complications. RESULTS: Seventeen women underwent the procedure, and the intact extraction of the specimen was successful in 16 out of the 17 cases (94%). No major complications were encountered during or after the procedure. CONCLUSION: Colpo-V incision is a simple and effective technique for the intact extraction of larger uterine specimens at hysterectomy.

Rectal Shaving for Bowel Endometriosis by Laparoscopic Reverse Submucosal Dissection for Easier, Safer and More Complete Excision of Disease.

STUDY OBJECTIVE: To demonstratefull-thickness excision of the affected muscularis along the submucosal plane. DESIGN: Stepwise demonstration of LRSD technique with narrated video footage. SETTING: LRSD takes advantage of the submucosal layer of the bowel wall and uses it as an easier line of excision for rectal endometriosis compared with the very difficult traditional line of excision of irregular disease-muscularis interface. The expansion of the submucosal layer by the injection separates the affected muscularis away from the mucosa, making it safer to excise the lesion with less chance of entering the bowel lumen. Excision of disease is more complete with LRSD because the full-thickness excision of the muscularis layer includes the healthy deep muscularis, which will form the disease-free deep excision margin. INTERVENTION: This video will highlight anatomic and technical aspects of LRSD including the following key steps: 1. Mobilization of diseased bowel segment 2. Submucosal injection 3. Circumferential incision of the muscularis 4. Submucosal dissection along the submucosal plane 5. Bowel wall integrity test 6. Muscularis defect repair CONCLUSION: Rectal shaving by LRSD appears to be easier, safer, and more complete in excision of bowel endometriosis than the classical rectal shaving technique. This modification requires further evaluation to confirm its potential in the surgical management of rectosigmoid deep infiltrative endometriosis.

Cultivating the Apprentice-Mentor Model for Minimally Invasive Gynaecology in the Era of Surgically Scarce Training: A Case Report of Laparoscopic Cornuostomy for Interstitial Ectopic Pregnancy by a Trainee.

Over the last few years, there is an apparent growing concern amongst O&G trainees of the inadequacy in exposure to minimally invasive gynaecology surgical training, which has been inadvertently compounded by the more stringent working hour regulations and disproportionately increasing number of trainees relative to surgical volume. Therefore, it is vitally important for trainees to maximise opportunities in the operating theatre and develop autonomy in carrying out more complex surgical procedures. This case report outlines the step-by-step approach of laparoscopic excision of a cornual ectopic pregnancy performed by a trainee under the supervision of a surgical mentor. This manuscript highlights key characteristic traits of a trainee that serve to foster surgical trust and simple but effective steps to foster surgical preparedness.

Shaving for Bowel Endometriosis.

STUDY OBJECTIVE: To demonstrate laparoscopic shaving of deeply infiltrative endometriosis affecting the rectosigmoid colon, with particular emphasis on the anatomic and technical aspects of the procedure. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Intestinal involvement in deep endometriosis is estimated to occur in 8% to 12% of patients, with 90% of occurrences being located in the colorectal segment. Deep endometriosis of the rectosigmoid is defined as endometriosis involving the muscular layer of the bowel wall, usually >5 mm deep, thus excluding superficial lesions that only affect the serosal layer. In cases in which medical therapy is unsatisfactory, rectosigmoid deep endometriosis can be surgically managed by 3 recognized surgical techniques: (1) rectal shaving, (2) disc excision, and (3) segmental resection. There are helpful recommendations for different approaches on the basis of the characteristics of the lesion, including the size, length, depth of invasion, involved rectal circumference, and number of lesions, among other factors [1]. Rectal shaving is well suited for smaller lesions, typically <3 cm, and involves "shaving" the lesion in the affected muscular layer of the bowel wall off the mucosa, ideally without entering the bowel lumen. It is associated with lower rates of perioperative complications and lower probability of long-term postoperative bladder and bowel dysfunctions [2]. INTERVENTIONS: This video demonstrates and highlights the anatomic and technical aspects of the following important steps of the rectal shaving procedure: (1) suspension of ovaries; (2) mobilization of the diseased segment of the rectum; (3) shaving of the lesions, with pertinent comments at different stages of nodule excision; (4) checking for the integrity of the bowel wall; and (5) suture of the muscularis defect after excision of the lesions from the muscularis layer of the bowel. CONCLUSION: Compared with other alternatives, shaving for bowel endometriosis is a more conservative procedure with lower rates of perioperative complications, and it is less likely to result in long-term bladder and bowel dysfunctions. Therefore, shaving is preferable and recommended for appropriate lesions.

Gender differences in perception of psychosocial distress and coping mechanisms among infertile men and women in Saudi Arabia.

The objective of the study was to evaluate the differences in psychosocial distress and coping mechanisms among infertile men and women in Saudi Arabia (SA). We performed a cross-sectional study of infertile patients (206 women and 200 men) attending infertility clinics in three referral hospitals in Riyadh, SA. A semi-structured questionnaire was developed to assess socio-demographic, clinical and psychosocial variables. Infertility-related psychosocial pressures were reported in 79 (39.7%) male and 97 (47.3%) female participants (p = 0.123). Males suffered more from intrusive questions and pressure to conceive, remarry or get divorced, while females were stressed more from psychological and emotional exhaustion, marital discord, attitudes of mothers-in-law or society, and persistent desire by the husband to have children. To cope with infertility, females engaged more in religious activities (p < 0.001) and spoke more to someone regarding their problems (p < 0.001). To solve their infertility problems, 50% tried to find solutions via the internet, and 38.5% of males and 51% of females reported using alternative medicines (p = 0.012). The patients with infertility in SA face multiple psychosocial stressors related to their infertility, and cope differently based on the gender and culture-specific knowledge of infertility. The female participants were significantly more affected from psychosocial stressors and the persistent desire by their spouse to have children.

Psychiatric disorders among infertile men and women attending three infertility clinics in Riyadh, Saudi Arabia.

BACKGROUND AND OBJECTIVES: No study has assessed psychiatric disorders among infertile men and women seeking fertility treatment in Saudi Arabia. Therefore, we sought to measure the rate of psychiatric disorders in this population. DESIGN AND SETTING: This was a cross-sectional observational study among patients attending infertility clinics at three referral hospitals in Riyadh, Saudi Arabia, between January 2013 and September 2014. PATIENTS AND METHODS: 406 patients (206 women and 200 men) participated in the study. The approved Arabic version of the MINI tool was used to assess 18 common psychiatric illnesses. RESULTS: The response rate was 81%. Of the men surveyed, only 4.5% self-reported having a psychiatric disorder. Of the women surveyed, only 10.2% reported having a psychiatric disorder. However, using the MINI scale, psychiatric illness was documented in 30% of males and 36.9% of females. The most common diagnoses for both genders were depression (21.7%) and anxiety (21.2%). Significantly more females than males exhibited suicidality and depression. In contrast, significantly more males than females had bipolar disorders and substance-related disorders. A low monthly income among male and female participants and polygamy among female participants were significantly associated with psychiatric disorders. CONCLUSIONS: This study shows that a higher prevalence of psychiatric disorders, particularly depression and anxiety, among infertile men and women in Saudi Arabia is associated with lower income and polygamy. This study highlights the importance of integrated care for alleviating the psychological burden of this unfortunate population and improving outcomes and quality of life. This study also encourages follow-up studies that aim to further understand the complex relationship between fertility and psychological well-being.

3-[4-(3,4-Dimethyl-5,5-dioxo-2H,4H-pyrazolo-[4,3-c][1,2]benzothia-zin-2-yl)phen-yl]-2-hy-droxy-1-mesitylprop-2-en-1-one hexane hemisolvate.

In the title compound, C(29)H(27)N(3)O(4)S·0.5C(6)H(14), the heterocyclic thia-zine ring adopts a half-chair conformation with the S and N atoms displaced by 0.500 (5) and 0.229 (5) Å, respectively, on opposite sides from the mean plane formed by the remaining ring atoms. The mean planes of the pyrazole ring and the benzene ring bonded to it form a dihedral angle of 35.76 (11)° and an intra-molecular O-H⋯O hydrogen bond ocurs. The crystal structure features O-H⋯O and C-H⋯O hydrogen bonds. There is a half-mol-ecule of hexane in the asymmetric unit lying about an inversion center. It is disordered over two sets of sites with occupancy factors 0.590 (9) and 0.410 (9).

4-(4-Bromo-phen-yl)-6-(4-chloro-phen-yl)-pyrimidin-2-ylamine.

The title compound, C(16)H(11)BrClN(3), contains pairs of mol-ecules lying about inversion centers linked by amino-pyrimidine N-H⋯N hydrogen bonds. The eight-membered rings thus formed are represented by the R(2) (2)(8) motif in graph-set notation. The second H atom of the amine group shows a rather weak inter-action with two Br atoms, resulting in bifurcated N-H⋯(Br,Br) hydrogen bonds. The dihedral angles between the mean planes of the benzene rings and the mean plane of the heterocyclic ring are 8.98 (15) and 35.58 (10)°. The Br and Cl atoms show substitutional disorder, with site-occupancy factors of 0.599 (2) and 0.401 (2), respectively.

Methyl 4-hydr-oxy-2H-1,2-benzothia-zine-3-carboxyl-ate 1,1-dioxide.

The asymmetric unit of the title compound, C(10)H(9)NO(5)S, contains two independent mol-ecules. The heterocyclic thia-zine rings in both mol-ecules adopt half-chair conformations, with the S atoms in each mol-ecule displaced by 0.455 (3) and 0.539 (3) Šand the N atoms displaced in the opposite direction by 0.214 (3) and 0.203 (3) Å, from the planes defined by the remaining ring atoms. The crystal structure is stabilized by O-H⋯O, N-H⋯O and C-H⋯O hydrogen bonds involving both inter- and intra-molecular inter-actions.

(2E)-3-(4-Chloro-phen-yl)-1-(1H-pyrrol-2-yl)prop-2-en-1-one.

In the mol-ecule of the title compound, C(13)H(10)ClNO, the benzene and pyrrole rings are oriented at a dihedral angle of 7.37 (12)°. In the crystal structure, inter-molecular N-H⋯O hydrogen bonds link the mol-ecules into centrosymmetric R(2) (2)(10) dimers. There are C-H⋯π inter-actions between benzene and pyrrole rings and a benzene C-H group. A weak π-π inter-action between the pyrrole rings [centroid-centroid distance 3.8515 (11) Å] further stabilizes the structure. There is also a π inter-action between the pyrrole ring and the carbonyl group, with a carbon-centroid distance of 3.4825 (18) Å.

4-(4-Fluoro-phen-yl)-6-(2-fur-yl)pyrimidin-2-amine.

Mol-ecules of the title compound, C(14)H(10)FN(3)O, are essentially planar and in the crystal structure they form dimers via hydrogen bonds, involving pyrimidinyl N atoms and amino H atoms, about inversion centers. The centroids of the furyl and pyrimidinyl rings are separated by 3.489 (2)Å, indicating π-π stacking inter-actions.

Synthesis, spectroscopic and cytotoxic studies of biologically active new schiff bases derived from p-nitrobenzaldehyde.

Thirteen new Schiff bases derived from p-nitrobenzaldehyde were synthesized by condensation with the appropriate amines. An unusual reduction of the p-nitrobenzaldehyde to the corresponding alcohol was also observed in one of the reactions. The structures of the compounds were identified using spectroscopic techniques. Cytotoxicity for the titled compounds was studied against Brine Shrimp, used as the test animal.